METABOLIC WAYNE CHENG, MD

BONES AND SPINE

OSTEOPENIA

• • VITAMINE D PRODUCTION

• VIT D2

• VIT D3

• 25-OH-VIT D3

• 1,25-OH VIT D3 VS. 24,25-OH VIT D3 OSTEOMALACIA- CLINICAL PRESENTATION

• Diffuse pain (away from joints) • Muscle weakness (waddling gait) • Hx of prior fx (rib/spine/long bone) OSTEOMALACIA X-RAY IN ADULTS

• Code fish vertebrae • Looser Zone OSTEOMALACIA- LAB.

• Ca, P, Akp, PTH, 25-vit D, 1,25-Vit D OSTEOMALACIA – LAB.

DISEASE CA P Akp PTH Vit.D Dep. Ricket L L H H VDRR (hypophosphotemic Nl L H N Ricket) * x link dominant H H H H *AR nl nl L nl hyperparathyroid H L H H Idiopathic Juvenil osteop. nl nl nl nl OSTEOMALACIA-TREATMENT

• Find the cause and treat it. OSTEOPOROSIS type I II Cause postmenopause age age 51-70 >70 F : M 6:1 2:1 Bone loss trabeculae Trabeculae+corticle Fx sites Crushed vert. Wedge vert. IT fx, wrist Femoral neck. OSTEOPOROSIS - HISTORY

• Menopause • Periods of amenorrhea • Nutrition • Inacitivity • Smoking • alcohol OSTEOPOROSIS-LAB

• CBC,ESR,CHEM20, SPEP,TSH,PTH OSTEOPOROSIS - IMAGING

• DXA(Dual-energy x-ray absorptiometry) • Classification I to IV levels (compare to peak bone mass of young same gender) • Two fold increase of Fx. Rate with each standard deviation. OSTEOPOROSIS-TREATMENT

• CALCIUM • Young adult = 1200 Mg/day • Premenopause = 1000 Mg/day • Postmenopause = 1500 Mg/day OSTEOPOROSIS-TREATMENT

• VIT D • 400 IU/DAY • 800 IU/DAY MAX. OSTEOPOROSIS-TREATMENT

• ESTROGEN • 0.625 MG/DAY • Contraindication: • Breast Cancer • Uterine Cancer • Thromboembolic disorders • Raloxifene(selective estrogen-receptor modulator) 60mg/day OSTEOPOROSIS - TREATMENT

• Bisphosphonates • 1st generation: Etidronate • 2nd generation: Alendronate • 5mg/day prevention • 10mg/day treatment • Instruction and side effects. • 3rd generation: Risedronate OSTEOPOROSIS TREATMENT

• Calcitonin • Salmon 200 IU/day • Has both analgesic and protective effects OSTEOPOROSIS TREATMENT

• Flouride • Increase bone formation but impair bone mineralization. (May increase bone density but increase rate of fractures) OSTEOPOROSIS TX. PROTOCOL

• Premenopause • Eumenorrheic • Ca 1000., Vit D 400, exercise • Amenorrheic • Above + estrogen or ocp OSTEOPOROSIS TX. PROTOCOL

• Postmenopause • BMD <2.5 • Ca 1500, Vit D. 400, estrogen

• BMD >2.5 or fracture • Above + calcitonin CONCLUSION

• Best treatment of osteoporosis is prevention. • Best treatment of osteomalacia is to treat the cause.